The Transitions program prepares homeless young people ages 17-22 for independence and adult living. It does this by providing a stable, safe place to live while enhancing the necessary personal, social, educational and occupational skills to live on their own.

Key Elements of the Transitions Program

Assessment of skills for independent living

Individual plan for reaching short term & life goals

Stable, safe living accommodations

Social skill development plan and practice

Counseling and support to continue education

Access to medical and mental health services

Skills for obtaining and maintaining employment

Access to substance abuse education & treatment if needed

Parenting skills

Adult mentors

Access to transportation

Group recreational, social and creative activities

Transitions Program Application

Complete the application by clicking the button below. The application will appear in a separate page. Complete all areas of the application and click submit at the bottom of the page. Please allow 30 minutes to complete all sections of the application. *** YOU MUST CLICK SUBMIT TO SEND YOUR APPLICATION OR YOUR INFORMATION WILL BE LOST****

Click here to open the Transitions Program Application.

Transitions Program Application

Referral Agency

Date

Applicant Referred by

Phone

Phone

(###)

###

####

PERSONAL INFORMATION

Name *

Name

First Name

Last Name

"Street" Name and/or Preferred Name

Email Address

Phone

Phone

(###)

###

####

Date of Birth

Age

Sex

Preferred Gender

Race/Ethnicity

If American Indian, please indicate tribe

Social Security Number

Are you a U.S. Veteran?

Yes

No

Are you currently homeless?

Yes

No

I don't know

If yes, where are you staying?

Couch Surfing with friends

Community Shelter

Camp Site

Outside/other/unknown

If you are not currently homeless, please list your address

If you are not currently homeless, please list your address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

INSURANCE

Do you have (or have you ever had) Medicaid or Health insurance of any kind?

Yes

No

I don't know

If yes, what coverage (Insurance Company or Medicaid #)

IF YOU ARE UNDER 18 YEARS OLD: Who is your Parent or Legal Guardian?

IF YOU ARE UNDER 18 YEARS OLD: Who is your Parent or Legal Guardian?

First Name

Last Name

Address - Parent or Legal Guardian

Address - Parent or Legal Guardian

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email - Parent or Legal Guardian

Phone - Parent or Legal Guardian

Phone - Parent or Legal Guardian

(###)

###

####

PREGNANT AND/OR PARENTING YOUTH

Are you currently pregnant or expecting a child?

Yes

No

I don't know

If yes, when is the child due?

If yes, is the child's mother/father currently involved?

Yes

No

Sometimes

If yes, what is the name and age of the child's mother/father

Do you currently have any biological children in YOUR full-time legal custody?

Yes

No

If yes, how many children?

If yes, please list names and ages

Do you currently have any biological children that are NOT in your full-time custody?

Yes

No

If yes, how many children?

If yes, please list names and ages

If yes, who is the child/children staying with?

If yes, do you have a legal plan to retain custody?

Yes

No

I don't know

Do you HAVE any of the following? (check all that apply)

TANF

WIC

OBGYN/Doctor

Child First Program Support

Parenting Classes

MENTAL HEALTH

Have you ever been diagnosed with any of the follow (check all that apply):

ADD/ADHD

Bi-polar

Depression

Schizophrenia

Anxiety

PTSD

Other

If other, please explain:

Do you currently (within the last 6 months) have a mental health care doctor and or counselor?